What is the first line treatment for geriatric behavioral disturbances such as anxiety and aggression associated with dementia?

First-Line Treatment for Geriatric Behavioral Disturbances in Dementia

Non-pharmacological interventions should be considered as the first-line treatment for geriatric behavioral disturbances such as anxiety and aggression associated with dementia. 1, 2

Assessment Before Treatment

• Before initiating any treatment, thoroughly investigate potential underlying causes of behavioral changes including pain, urinary tract infections, constipation, dehydration, and medication side effects 1, 2
• Use a structured approach such as DICE (Describe, Investigate, Create, Evaluate) to systematically assess and manage neuropsychiatric symptoms 1
• Document specific behaviors rather than general terms (e.g., "strikes out during bathing" rather than "agitation") to identify patterns and triggers 1
• Evaluate the patient's medication profile, particularly those with anticholinergic properties that may worsen cognitive symptoms 1, 3

Non-Pharmacological Interventions

Environmental Modifications

• Simplify the environment and avoid overstimulation that may trigger anxiety or aggression 2, 4
• Use orientation cues such as calendars, clocks, and labels to reduce confusion 2
• Install safety features like handrails in bathrooms where agitation often occurs 2

Behavioral Approaches

• Implement structured daily routines with regular times for meals, exercise, and sleep 2, 5
• Provide individualized activities that match the patient's abilities and previous interests 2, 4
• Use the ABC (antecedent-behavior-consequence) approach to identify and modify triggers 2, 5

Communication Strategies

• Use calm tones, simple one-step commands, and gentle touch for reassurance 2, 5
• Avoid complex instructions, harsh tones, or confrontational approaches that may escalate behaviors 5
• Involve caregivers in training and implementation of behavioral strategies 1, 4

Pharmacological Interventions

Pharmacological treatments should only be considered when:

• Non-pharmacological approaches have been ineffective 1, 2, 3
• There is significant risk of harm to the patient or others 2, 3
• Symptoms cause severe distress to the patient 3

Medication Considerations

• Atypical antipsychotics may be considered only for severe behavioral symptoms with psychotic features, but carry significant risks including increased mortality 1, 3
• Avoid medications with significant anticholinergic effects that can worsen cognitive symptoms 2, 3
• Traditional antipsychotics like haloperidol should not be first-line choices due to higher risk of side effects 3
• Avoid thioridazine, chlorpromazine, or trazodone for treating behavioral symptoms 3

Monitoring and Follow-up

• Evaluate response to any intervention within 30 days 2, 3
• For patients on psychotropic medications, conduct close monitoring for adverse effects 2, 3
• Consider gradual dose reduction or discontinuation of pharmacological treatment after 6 months of symptom stabilization 3, 5
• Regularly reassess the need for continued medication as symptoms fluctuate throughout the course of dementia 3, 5

Common Pitfalls to Avoid

• Relying exclusively on medications without implementing non-pharmacological strategies 2, 3
• Failing to identify and address underlying causes of behavioral symptoms 1, 2
• Underestimating the role of pain and discomfort as triggers for behavioral disturbances 2, 5
• Using medications with significant anticholinergic effects 3
• Inadequate training of caregivers and staff in behavioral management techniques 1, 4

The evidence strongly supports starting with non-pharmacological approaches that address the underlying causes of behavioral symptoms while minimizing risks to the patient's health and quality of life 1, 6.